Seattle Central College Dental Hygiene Clinic Treatment and Financial Summary 2120 S. Jackson Seattle, WA 98144 206.934.4423 ADA Code Procedure Fee DIAGNOSTIC Instr. Initials ADA Code Fee Procedure Instr. Initials SEXTANT TREATMENT: CIRCLE SEXTANT CLEANED Clinical Oral Evaluation D0140 D0150 Limited Oral EvalComprehensive Oral Eval $18.00 D0120 Periodic Oral Eval $ 7.00 D9430 Limited Oral EvalTissue re-eval or PSR N/C Radiographs/Diagnostic Imaging D0210 D0220 00230 Complete series (inc. BWX)) (20 films) Periapical (1st film) Periapical (each additional) $28.00 $ 4.00 $ 3.00 D0240 Occlusal film $ 4.00 D0270 Single bitewing $ 4.00 D0272 D0274 D0277 PERIODONTICS $7.00 Problem Focused Bitewings (2 films) Bitewings (4 films) Perio survey (7 bitewings) $ 9.00 $14.00 D4341 Sextant D4341 Sextant D4341 Sextant D4341 Sextant D4341 D4342 UR PSRP (2 quad Equiv.) 1 2 (4 or more teeth) UL PSRP (2 quad Equiv.) 2 3 (4 or more teeth) LR PSRP (2 quad Equiv.) 5 6 (4 or more teeth) LL PSRP (2 quad Equiv.) 4 5 (4 or more teeth) SCCD student PSRP per quad Quad ______ UR PSRP (1-3 teeth) UL PSRP (1-3 teeth) LR PSRP (1-3 teeth) $22.00 $44.00 $22.00 $44.00 $22.00 $44.00 $22.00 $44.00 D4342 LL PSRP $22.00 D4355 Full mouth debridement $ 44.00 D4381 Local antimicrobial delivery $8.00 D4342 D4342 D4342 (1-3 teeth) $14.00 $22.00 $22.00 $22.00 Other Periodontal Services $18.00 D0330 Panoramic film $28.00 D4999 Unspecified procedure N/C D0350 E0/I0 Imaging N/C D4910 Periodontal maintenance $38.00 D4910 Student Perio Maintenance $14.00 Tests and Laboratory Examinations D0460 Vitality tests N/C D0470 Diagnostic casts N/C Date Patient # PREVENTIVE Patient name Dental Prophylaxis D1110 D1110 Adult prophylaxis SCCD Student $28.00 $14.00 Student name Charges Page 1 Topical Fluoride – Office Procedure D1206 Fluoride Varnish $7.00 D1208 Fluoride Gel $7.00 D1310 Nutritional counseling N/C D1320 Tobacco counseling N/C D1330 Oral hygiene instructions N/C D1351 Sealant (per tooth) total # $12.00 Other Preventive Services Page 2 TOTAL CASH CHECK # _________ PSR Int. _________ CREDIT #________ PAID Did patient take copy of x-rays today? (Please circle) Yes No Seattle Central College Dental Hygiene Clinic Treatment and Financial Summary 2120 S. Jackson Seattle, WA 98144 206.934.4423 Home Care Aids Restorative Amalgam tooth/surf Code Product Fee D2140 Amalgam – one surface $45.00 P001 Toothbrushes $2.00 D2150 Amalgam – two surfaces $55.00 P002 Proxy brush w/2 refills $2.00 D2160 Amalgam – three surfaces $60.00 P003 Proxy brush refills - 2 $1.00 D2161 Amalgam – four + surfaces $70.00 P004 Travel proxy brush $1.00 P005 Compact Interdental brush $1.00 D2391 Composite – one surface (single pit or PRR) $55.00 P006 End Tuft brush $2.00 D2391 Composite – one surface $60.00 P007 Go Betweens - 2 $1.00 D2392 Composite – two surfaces $70.00 P008 Postcare flossing aid for implants $1.00 D2393 Composite – three surfaces $80.00 P009 Floss (one free with prophy) - 2 $1.00 D2394 Composite – three + surfaces $90.00 P010 Sulcular toothbrush $2.00 P011 Oral B Ultra floss – 2 pkg. $1.00 P012 Superfloss $1.00 P013 Floss handle $3.00 P014 Floss Threaders (pkg) – 2 pkg. $1.00 P015 Reach Access Flosser $1.00 P016 Stimulator $2.00 P017 Plastic Mouth Mirror $1.00 P018 Perio Aid $2.00 P019 Stimudents – 2 pkg. $1.00 P020 Plackers – plastic piks $2.00 P021 Gingival Irrigator s/syringe $2.00 -$5.00 P022 Tongue Scraper $3.00 P023 1.1% Sodium Fluoride Paste/Gel $10.00 $10.00 P025 Chlorhexidine Rinse $12.00 $10.00 P026 Perioguard $12.00 P027 Denture Holder $3.00 P028 Denture brush $2.00 P029 Other $ P030 Other $ Composite-Posterior Composite-Anterior D2330 Composite – one surface $60.00 D2331 Composite – two surfaces $70.00 D2332 Composite – three surfaces $80.00 D2335 Composite – four+ surfaces $90.00 Adjunctive General Services D9230 D9230 Nitrous Oxide Sedation (15 min) Nitrous Oxide Sedation (per hour) $8.00 $20.00 Drugs by Report D9630 Other Drugs and/or Medicaments PP Miscellaneous D9910 D9911 Desensitizing Agents (per appointment) Desensitizing Resins (per appointment) D9110 Palliative Treatment PP D9999 Unspecified Adjunct Procedure PP Total (Rev. 6/2014) Total
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